Dates Of Service For Purchased Items Cannot Be Ranged. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. The service is not reimbursable for the members benefit plan. Use This Claim Number If You Resubmit. Please Clarify Services Rendered/provide A Complete Description Of Service. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). (National Drug Code). Services have been determined by DHCAA to be non-emergency. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. wellcare explanation of payment codes and comments. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. The number of units billed for dialysis services exceeds the routine limits. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Claims may deny when DXA bone density studies (CPT 77080 or 77081) are billed and the only diagnosis on the claim is osteoporosis screening (ICD-10 code Z13.820) for a woman who is under age 65 or for a man who is under age 70. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Denied. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. This Claim Has Been Manually Priced Based On Family Deductible. Only One Ventilator Allowed As Per Stated Condition Of The Member. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. This drug is not covered for Core Plan members. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. The Modifier For The Proc Code Is Invalid. Member is not Medicare enrolled and/or provider is not Medicare certified. This service or a related service performed on this date has already been billed by another provider and paid. Service Denied. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. This claim is being denied because it is an exact duplicate of claim submitted. Disposable medical supplies are payable only once per trip, per member, per provider. Less Expensive Alternative Services Are Available For This Member. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Member Name Missing. Please Disregard Additional Informational Messages For This Claim. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Excessive height and/or weight reported on claim. Diagnosis Treatment Indicator is invalid. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Members do not have to wait for the post office to deliver their EOB in a paper format. Denied. Denied. Staywell is committed to continually improving its claims review and payment processes. A standard 12-lead electrocardiogram should be obtained first for patients with a diagnosis of syncope and collapse before performing advanced imaging procedures. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Remark Codes: N20. This change to be effective 4/1/2008: Submission/billing error(s). Denied/Cutback. Denied. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Denied. qatar to toronto flight status. Check Your Current/previous Payment Reports forPayment. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Header To Date Of Service(DOS) is invalid. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. A Separate Notification Letter Is Being Sent. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. A quantity dispensed is required. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. OA 14 The date of birth follows the date of service. Rendering Provider is not certified for the Date(s) of Service. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Please Correct And Resubmit. Pricing Adjustment/ Claim has pricing cutback amount applied. The Information Provided Indicates Regression Of The Member. Training Reimbursement DeniedDue To late Billing. Normal delivery payment includes the induction of labor. Pharmacuetical care limitation exceeded. Prescribing Provider UPIN Or Provider Number Missing. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Please Correct And Resubmit. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Compound Drug Service Denied. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. This National Drug Code (NDC) is not covered. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. NCTracks Contact Center. Services Can Only Be Authorized Through One Year From The Prescription Date. This National Drug Code (NDC) has Encounter Indicator restrictions. WellCare has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. PleaseReference Payment Report Mailed Separately. The Revenue Code is not reimbursable for the Date Of Service(DOS). Revenue code submitted with the total charge not equal to the rate times number of units. Denied due to Services Billed On Wrong Claim Form. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Accommodation Days Missing/invalid. A valid Prior Authorization is required for non-preferred drugs. Member is enrolled in Medicare Part A on the Date(s) of Service. Formal Speech Therapy Is Not Needed. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Denied. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Take care to review your EOB to ensure you understand recent charges and they all are accurate. Claim Has Been Adjusted Due To Previous Overpayment. snapchat chat bitmoji peeking. Claim Denied. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. An antipsychotic drug has recently been dispensed for this member. Prior Authorization (PA) is required for this service. The Request Has Been Approved To The Maximum Allowable Level. Services billed exceed prior authorized amount. The Members Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Restorative Nursing Involvement Should Be Increased. OA 13 The date of death precedes the date of service. Reimbursement For This Service Has Been Approved. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. The service was previously paid for this Date Of Service(DOS). "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. Denied. Documentation Does Not Justify Reconsideration For Payment. Claim Denied Due To Invalid Occurrence Code(s). Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Unable To Process Your Adjustment Request due to Provider ID Not Present. Individual Test Paid. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Occurance code or occurance date is invalid. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Diag Restriction On ICD9 Coverage Rule edit. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Pricing Adjustment/ Paid according to program policy. Seventh Occurrence Code Date is required. Service Denied. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Claims may deny when a nerve conduction study is billed without a needle EMG, or a needle EMG is billed without a Nerve conduction study, and the only diagnosis is radiculopathy (ICD-10 codes M50.1-M50.23, M51.1-M51.27, M51.9, M53.80, M54.10-M54.18, M54.30-M54.42, and M79.2). Pricing Adjustment/ Ambulatory Surgery pricing applied. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Pricing Adjustment/ Pharmacy pricing applied. Claim Is Being Reprocessed Through The System. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Surgical Procedure Code is not related to Principal Diagnosis Code. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . Claim Is Pended For 60 Days. Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report. Billing Provider is restricted from submitting electronic claims. If You Have Already Obtained SSOP, Please Disregard This Message. Denied/Cutback. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Submit Claim To Other Insurance Carrier. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Billing Provider ID is missing or unidentifiable. The detail From Date Of Service(DOS) is invalid. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. The Service Requested Is Inappropriate For The Members Diagnosis. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Pharmaceutical care indicates the prescription was not filled. Service Denied. Denied/Cutback. Invalid modifier removed from primary procedure code billed. Denied/cutback. Member is assigned to an Inpatient Hospital provider. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Claim Denied/cutback. This National Drug Code (NDC) has diagnosis restrictions. Medical explanation of benefits. This National Drug Code (NDC) is only payable as part of a compound drug. One or more Diagnosis Codes has a gender restriction. A valid procedure code is required on WWWP institutional claims. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Multiple Unloaded Trips For Same Day/same Recip. The Medical Need For This Service Is Not Supported By The Submitted Documentation. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Denied. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. A Payment Has Already Been Issued For This SSN. To allow for Medicare Pricing correct detail denials and resubmit. The Rendering Providers taxonomy code in the header is not valid. Claim Is Being Special Handled, No Action On Your Part Required. Resubmit charges for covered service(s) denied by Medicare on a claim. Please Clarify The Number Of Allergy Tests Performed. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. This service is not covered under the ESRD benefit. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). Denied. Amount Recouped For Mother Baby Payment (newborn). The Member Is Only Eligible For Maintenance Hours. Approved. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. To allow for multiple biopsies for investigation and diagnosis of certain disease entities, WellCare applies max units editing for CPT code 88305 based on gastrointestinal (GI) and prostate-related diagnoses. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Claim date(s) of service modified to adhere to Policy. Code. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Two Informational Modifiers Required When Billing This Procedure Code. Rn Visit Every Other Week Is Sufficient For Med Set-up. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. This limitation may only exceeded for x-rays when an emergency is indicated. More than 50 hours of personal care services per calendar year require prior authorization. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Recouped. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Service(s) Approved By DHS Transportation Consultant. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Pricing Adjustment/ Revenue code flat rate pricing applied. Incidental modifier is required for secondary Procedure Code. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. To better assist you, please first select your state. By continuing to use our site, you agree to our Privacy Policy and Terms of Use.